Oxygen is an essential medical treatment to save human lives. But, in recent weeks, it’s become clear just how vital it is as India reels from a deadly surge in COVID-19 cases. Express trains are racing across the country to deliver oxygen from the eastern town of Angul to the capital of Delhi and other regions. Meanwhile, desperate pleas fill social media from people forced to helplessly watch their family members slowly suffocate.
Throughout the COVID-19 pandemic, medical oxygen shortages have struck hospitals in Brazil, Peru, Nigeria, Jordan, Italy, and beyond. In the United States, too, oxygen supplies at hospitals in New York City and California have run dangerously low at times. Combined with the crisis in India, these have now captured international attention.
But these shortages are far from a new phenomenon. Experts say the pandemic is exacerbating the oxygen access gap that causes an untold number of preventable deaths every year in low- and middle-income countries.
“What COVID has done is expose how fragile actually the systems around oxygen have been over the years,” says Mphu Ramatlapeng, executive vice president for implementation at the Clinton Health Access Initiative (CHAI), which was recently a finalist for a $100 million grant from the MacArthur Foundation to fund its proposal to ensure oxygen access in India, Nigeria, Ethiopia, Kenya, and Uganda. “My worst nightmare was something like COVID happening.”
Why is it such a challenge for countries to get enough oxygen, one of the most fundamental of life-giving elements? Here’s a look at the complexities of delivering medical oxygen, how scientists are working to find solutions, and how the pandemic has prompted the international community to respond more forcefully—before another country becomes the next India.
The oxygen access gap
Medical oxygen is a more concentrated form of oxygen than what’s in the air that you breathe. The Earth’s atmosphere is actually mostly nitrogen—only 21 percent of regular air is oxygen. Medical oxygen, however, is a minimum of 82 percent pure oxygen, which can be achieved through a chemical process. Its modern use as a therapeutic drug dates back to World War I, when it was administered to soldiers exposed to mustard gas in the trenches across Europe.
Oxygen therapy is particularly critical for respiratory illnesses such as COVID-19 or pneumonia, which is the leading cause of death in children in low-income countries. One major fatal complication of pneumonia is hypoxemia—which occurs when a person has low levels of oxygen in their blood. When blood oxygen is low, the body’s organs begin to shut down.
“Your cells need oxygen to survive,” says Michael Hawkes, assistant professor of pediatrics at the University of Alberta who oversees a solar-powered oxygen delivery program that works primarily in Uganda. “The whole reason we have a blood supply is to get oxygen to them.”
Oxygen is also potentially life-saving for various other reasons. Hypoxemia can be a complication of everything from severe malaria and cardiovascular disease to traumas in which patients lose a lot of blood. Supplemental oxygen helps buy the body time while doctors treat the source of the problem. Doctors also administer oxygen when patients are put under anesthesia in surgery.
“The use of oxygen is pretty much in every aspect of our lives in the medical world,” Ramatlapeng says.
But oxygen isn’t always easily available for patients in low- and middle-income countries. In 2014, a study of hospitals in Malawi found that only 22 percent of patients who needed oxygen received it. A 2019 study of hospitals in southwest Nigeria found that they were only able to provide oxygen to 20 percent of the children who needed it. And a 2020 study found that improving the quality of the oxygen program at health facilities in Papua New Guinea reduced overall pediatric death by 40 percent and death by pneumonia by 50 percent.
“That’s been essentially a decade’s work that shows that if you put oxygen into remote health facilities where pneumonia is a common problem among children at least, you can reduce mortality by 50 percent,” says Trevor Duke, lead author on the study, and a pediatrician at the University of Melbourne and adjunct professor of child health at the University of Papua New Guinea.
Despite clear evidence that medical oxygen saves lives, there are many complex challenges to actually getting it to health care facilities—starting with the way oxygen is delivered in the first place.
Cylinders, concentrators, and piped oxygen
Oxygen delivery systems look different depending on location: large or small facilities; urban or rural environments; or high- or low-income communities.
Major health care facilities around the world rely on bulk oxygen. In this system, hospitals have enormous tanks of liquid oxygen on site, which they then pipe throughout the hospital and can be turned on and off like a spigot. This system is cost-prohibitive for smaller health facilities. It requires access to gas companies—which have a relative monopoly on the market—to fill up the tanks. It’s also an enormous investment to build pipelines that Duke says will “invariably leak” in low-income settings.
Instead, health facilities in rural or low-income communities typically get medical oxygen in individual cylinders that gas companies fill at oxygen plants. But the highly pressurized cylinders are heavy and dangerous, making them expensive to transport—particularly to remote villages that are hundreds of miles from an oxygen plant. Cylinders are also constantly running out. They typically only have enough oxygen to last an adult between one and three days, meaning that a health facility needs to have a lot of backups on hand.
“You’ve seen the pictures from India of people dying because their oxygen runs out,” Duke says. “So there are better ways of doing it where there are continuous supplies of oxygen like oxygen concentrators.”
Oxygen concentrators have been around since the 1970s. These machines contain zeolite crystals that absorb the nitrogen from regular air, leaving concentrated oxygen that flows to a patient through tubes connected to nasal prongs. One oxygen concentrator can provide oxygen to two children at a time. But they require steady electricity, which isn’t always available.
“A power outage can be fatal,” says Hawkes. “If it goes out even just for a few minutes, a child could die.”
That’s why many who are working to bridge the oxygen access gap have turned to solar concentrators, which work in the same way but are powered by solar panels and batteries rather than electricity. There’s also a rising use of oxygen generators, which are essentially much bigger oxygen concentrators that mid-sized regional hospitals can use to fill cylinders for smaller facilities in their district—a hub-and-spoke model.
For more low- and middle-income communities, Duke says having a combination of solar concentrators and oxygen generators is best. But as shown in the 2020 study of rural hospitals in Papua New Guinea, where Duke has been working for nearly three decades, a successful oxygen program also requires a different kind of investment.
“It’s simple to give someone in India an oxygen cylinder and a face mask and let them go,” he says. “But that’s not a system, it’s a Band-Aid.”
Pulse oximeters and staff training
You need more than just access to oxygen to be able to reliably provide it to patients. Health care facilities must have staff with the expertise to use and maintain oxygen concentrators, which Hawkes says might otherwise have a lifespan of six months to a year. They also have to have a strong supply management system in place so that staff know when it’s time to reorder oxygen cylinders, ensuring they’re always on hand.
They also must have the ability to diagnose hypoxemia in the first place. Hypoxemia is hard to detect in its early stages, with few clinical symptoms until it progresses to the point where a patient is gasping for breath.
That’s where pulse oximeters typically come in. Invented in the 1970s, these small electronic devices that clamp onto a person’s finger to measure blood oxygen saturation became a standard of care in U.S. hospitals by the end of the ‘80s. They are so common in some countries that many Americans panic-bought them early in the pandemic.
“It’s important to have it at the entry point in a medical facility,” Ramatlapeng says.
But Ramatlapeng adds that pulse oximeters aren’t available in 90 percent of the health care facilities in the countries where the Clinton Health Access Initiative works. In many cases, they’re simply not yet seen as vital in the same way as blood pressure machines and thermometers.
That’s partly due to the way that deaths are reported. Hypoxemia is rarely reported as a cause of death except in rare cases like, for example, mountaineers. Instead, the disease itself—pneumonia, malaria, cardiovascular disease—is more likely to be listed on a death certificate. Ramatlapeng says that this is why even health care professionals don’t always realize how many lives are truly lost to hypoxemia.
“People and children have been dying due to the lack of oxygen for years and years,” she says. “We think oxygen must take center stage now.”
An essential—but neglected—medicine
Closing the oxygen access gap is going to take significant investment from the international community—which has historically been lacking in a funding landscape that Duke says tends to prioritize new drugs and vaccines.
“It’s an essential medicine that has been neglected,” Duke says. “Oxygen is an essential drug, but it’s a very old drug. So there’s been a low priority on oxygen generally.”
Yet there’s some reason to hope that the COVID-19 pandemic could trigger a shift in those priorities as it highlights how critical medical oxygen truly is for saving lives.
Last fall, a coalition of NGOs launched the COVID-19 Oxygen Needs Tracker, which allows funders to see in real time how many cubic meters of oxygen are needed in low- and middle-income countries each day. The results were so staggering that the WHO launched a COVID-19 Oxygen Emergency Taskforce in February with the goal to secure $90 million in immediate funding for oxygen needs in low- and middle-income countries and $1.6 billion in funding for the next year.
Robert Matiru, director of programs at Unitaid, a global health agency that is leading the taskforce, acknowledged that oxygen needs were slow to gain traction among funders.
“It should have been a wake-up call before India,” Matiru says. “It shouldn’t have taken something like this for governments to see just how important this is.”
Matiru says the WHO taskforce has four main objectives: bring attention to the oxygen crisis, price out the oxygen needs of low- and middle-income countries, link those needs to financing, and drive down the price of oxygen. Although the taskforce will focus on COVID-19 needs, it could have long-term implications for closing the oxygen access gap.
“The good thing is that by investing in medical oxygen for COVID you’re also investing in medical oxygen systems,” Matiru says, pointing out, too, that the acute pandemic needs are in fact long-term needs in many low-income countries where the vaccine rollout is slow.
Duke worries, however, that the response will not be fast enough to spare countries that are likely to experience their own surges in COVID-19 cases and are even more vulnerable than India. Still, he hopes that the pandemic will trigger a new understanding of the importance of investing in good oxygen systems rather than just the latest technology.
“The best time to do something was several years ago, but it’s not too late now.”
Editor's Note: The story has been updated to identify Unitaid as a global health agency.